Navigator Program Intake Form

The personal data collected on the on-line Navigator Intake Form is used to determine your eligibility for admission and to schedule an intake meeting when appropriate. The information is kept confidential.

Please take a few minutes to answer the following questions, so that we can better meet your needs. This form will be part of your child or teen’s medical record, and is confidential.

Required fields *

Who is filling in this form?

I have consent from the legal guardian to submit this form.

Yes

The Navigator Program helps parents and caregivers caring for a child or teen with complex medical needs. It provides non-medical supports to help parents and caregivers in their caregiving role.

Please check the boxes to let us know what kind of help you’re looking for.

Achieving employment or education goals

Connecting to peer support

Creating self-care techniques

Strengthening relationship health

Improving knowledge and access to key supports

Managing the day to day issues

Finding accessible recreation

Coping with stress

Expanding your social support network

Other:

What would you like to see happen as a result of this referral?

Please check all care providers and services the family is involved with:

Ottawa Children’s Treatment Centre

Children’s Aid Society

Rotary Home

Community Care Access Centre

Service Coordination

Roger Neilson House

Other:

Information about your child or teen:

First name

Last name

Age

Gender

Child or teen’s primary address:

Parent or Guardian

Relationship to child or teen:

Phone number

Email Address

What is the best way for us to contact you?

What language is best for you?

Do you need an Interpreter?

Please share any other information you think is important for us to know:

Form Builder

Navigator Program Intake Form

Information about your child or teen: